1. (1) The Division may consider coverage for commodes when:

   1. (a) The client is physically incapable of utilizing regular toilet facilities. This would occur when the client is confined to:

      1. (A) A single room; or
      2. (B) One level of the home environment and there is no toilet on that level; or
      3. (C) The home and there are no toilet facilities in the home.
   2. (b) Extra-wide/heavy-duty commodes may be covered when a client weighs 300 pounds or more and meets the conditions of coverage for commodes;

   3. (c) Only bariatric commodes coded as E1399 (durable medical equipment, miscellaneous) may be covered for a client residing in a nursing facility, subject to service limitations of Division rules, when all of the following requirements are met:

      1. (A) The client meets the conditions of coverage as specified in this rule; and
      2. (B) The bariatric commode has been assigned code E1399 by the Medicare Pricing, Data Analysis and Coding (PDAC) contractor.
   4. (d) A commode with detachable arms (E0165) may be covered if the detachable arms feature is necessary to facilitate transferring the client or if the client has a body configuration that requires extra width.
   5. (e) A commode with integrated seat lift mechanism (E0170, E0171) is covered if it is medically appropriate and client meets criteria for a seat lift mechanism. A commode with seat lift mechanism is intended to allow the client to walk after standing.(f) Toilet seat lift mechanisms (E0172) and footrests (E0175) are not primarily medical in nature.

2. (2) Documentation requirements:

   1. (a) Documentation must include the practitioner’s order, the client’s height and weight and information supporting the medical appropriateness for the commode dispensed;
   2. (b) For codes requiring prior authorization (PA), submit documentation which supports conditions of coverage are met as specified in this rule.

3. (3) Procedure Codes: Table 122-0600 Toilet Supplies.

   [ED. NOTE: Tables referenced are available from the agency.]

   [ED. NOTE: To view attachments referenced in rule text, click here for PDF copy.]

Statutory/Other Authority

ORS 413.042 & 414.065

Statutes/Other Implemented

ORS 414.065

History

DMAP 23-2024, minor correction filed 01/04/2024, effective 01/04/2024
DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024
DMAP 15-2009, f. 6-12-09, cert. ef. 7-1-09
DMAP 12-2007, f. 6-29-07, cert. ef. 7-1-07
OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07
OMAP 44-2004, f. & cert. ef. 7-1-04
OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03
OMAP 47-2002, f. & cert. ef. 10-1-02
OMAP 8-2002, f. & cert. ef. 4-1-02
OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01
OMAP 4-2001, f. 3-30-01, cert. ef. 4-1-01
OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00
OMAP 13-1999, f. & cert. ef. 4-1-99
HR 17-1996, f. & cert. ef. 8-1-96
HR 26-1994, f. & cert. ef. 7-1-94
HR 10-1994, f. & cert. ef. 2-15-94
HR 9-1993, f. & cert. ef. 4-1-93
HR 32-1992, f. & cert. ef. 10-1-92
HR 13-1991, f. & cert. ef. 3-1-91